FORM ST

1.	Name of the assessee	:
2.	Address of the assessee	:
2a.	Pan Number	:
3.	Address of the premises to be registered	:
4.	Category of the service	:
5.	Fax / telex and phone number	:
6.	Form of organization (individual /company / partnership, etc.)	:
7.	Additional information required in the case of stock-broker	:
	a) Name of the member, with code No.	:
	b) Name of stock exchange registered with	:
	c) Date of admission of membership	:
	d) Whether member of more than one stock exchange? If so, please give name of the stock exchange with code number	:
	e) Registration number allotted by Securities and Exchange Board of India (copy of certificate of registration may be enclosed or a copy of application for registration with SEBI may be enclosed)	:
8.	I/ We _________________________ agree to abide by all the provisions of Service Tax Rules, 1994, and any order issued there under.
9.	I/ We ________________declare to the best of my / our knowledge and belief that the information furnished herein is true and complete.

	Place :
	Date :
	Signature of assessee or his }authorized representative